Form Dhcs 7037 - California Pickle Resource Work Sheet - Health And Human Services Agency

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State of California—Health and Human Services Agency
D epartment of Health Care Services
PICKLE RESOURCE WORK SHEET
Applicant's name
Case name
Case number
I.
Real Property
Total equity value of nonexcluded real property
$ ===============
II.
Personal Property
A. Total cash on hand
$_____________
B. Total cash in financial institution
$_____________
C. Amount in excess of $1,500 in separately identifiable burial fund
$_____________
D. Total cash surrender value (CSV) of life insurance (if total face
$_____________
value exceeds $1,500 per individual, count CSV of all policies)
E. Amount in excess of $1,800 in burial trust or contract
$_____________
F. Current market value (CMV) of nonexcluded vehicles in excess of
$_____________
$4,500 (including RV, trailer, etc.)
G. Total equity value of additional nonexcluded vehicles
$_____________
H. Total value nonexcluded personal property
$ ===============
III.
Household Goods
1,000
A. Presumed value of household goods and personal effects
$_____________
B. CMV of unusual items (list individual items) from MC 210 or MC 210B
______________________________
$_____________
______________________________
$_____________
______________________________
$_____________
C. Total CMV of unusual items
$_____________
D. Total household goods (III. a. + c.)
$_____________
2,000
IV.
Excluded Value of Household Goods
– $_____________
V.
Total Value of Nonexcluded Household Goods and Items of Unusual
Value (Sum of Parts III. d. minus Part IV.)
$ ===============
VI.
Total Value of Nonexcluded Resources (Sum of Part I., II., and V.)
= $ ===============
VII.
Resource Limit for Pickle FBU (SEE RESOURCE CHART)
______________
$_____________
U
U
VIII.
Resource Eligible for Pickle?
YES
NO
Note: When determining Pickle eligibility, a person must be within the resource limit at 12:01 a.m. on the first day of the month
for which eligibility is being determined.
DHCS 7037 (05/07)

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